Conversion to open surgery in obese patients undergoing minimally invasive distal pancreatectomy: results from a multicenter analysis.

BACKGROUND: Although minimally invasive distal pancreatectomy (MIDP) is considered a standard approach it still presents a non-negligible rate of conversion to open that is mainly related to some difficulty factors, as obesity. The aim of this study is to analyze the preoperative factors associated with conversion in obese patients with MIDP. METHODS: In this multicenter study, all obese patients who underwent MIDP at 18 international expert centers were included. The preoperative factors associated with conversion to open surgery were analyzed. RESULTS: Out of 436 patients, 91 (20.9%) underwent conversion to open, presenting higher blood loss, longer operative time and similar rate of major complications. Twenty (22%) patients received emergent conversion. At univariate analysis, the type of approach, radiological invasion of adjacent organs, preoperative enlarged lymphnodes and ASA ≥ III were significantly associated with conversion to open. At multivariate analysis, robotic approach showed a significantly lower conversion rate (14.6 % vs 27.3%, OR = 2.380, p = 0.001). ASA ≥ III (OR = 2.391, p = 0.002) and preoperative enlarged lymphnodes (OR = 3.836, p = 0.003) were also independently associated with conversion. CONCLUSION: Conversion rate is significantly lower in patients undergoing robotic approach. Radiological enlarged lymphnodes and ASA ≥ III are also associated with conversion to open. Conversion is associated with poorer perioperative outcomes, especially in case of intraoperative hemorrhage.

Robotic versus laparoscopic distal pancreatectomy in obese patients.

BACKGROUND: Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS: In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS: Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS: In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

OBJECTIVE: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis.

BACKGROUND: A variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery. METHODS: We performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period. RESULTS: One hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified. CONCLUSION: HJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

Trans-gastric pancreaticogastrostomy reconstruction after pylorus-preserving robotic Whipple: a proposal for a standardized technique.

BACKGROUND: A number of technical improvements regarding the pancreatic anastomosis have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) remains is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. MATERIALS AND METHODS: This study is a retrospective review of a prospectively maintained database. Data were collected from all consecutive robot-assisted pancreaticoduodenectomies (RAPD), performed by a single surgeon, at the University of Illinois Hospital & Health Sciences System, between September 2007 and January 2016. RESULTS: A total of 28 consecutive patients (16 male and 12 female) who underwent a RAPD were included in this study. Patients had a mean age and mean BMI of 61.5 years (SD = 12.3) and 27 kg/m2 (SD = 4.9), respectively. The mean operative time was 468.2 min (SD = 73.7) and the average estimated blood loss was 216.1 ml (SD = 113.1). The mean length of hospitalization was 13.1 days (SD = 5.4). There was no clinically significant POPF registered. CONCLUSION: Trans-gastric pancreaticogastrostomy (TPG) represents a valid and feasible option as a pancreatic digestive reconstruction during RAPD. Initial results showed decreased incidence of POPF with an increased risk of postoperative bleeding. Our experience suggests that TPG might be safer than pancreaticojejunostomy (PJ); further studies are needed in order to confirm.

Totally replaced right hepatic artery in pancreaticoduodenectomy: is this anatomical condition a contraindication to minimally invasive surgery?

BACKGROUND: The appropriate approach, in the case of an aberrant right hepatic artery (RHA) during open pancreaticoduodenectomy (PD), has already been established. The aim of our study is to analyze the short-term surgical and oncological outcomes after robotic PD in patients with anatomical variants, with a special focus on totally replaced RHA. METHODS: This study is a retrospective review of a prospectively maintained database collected from consecutive patients who underwent robotic PD at the University of Illinois Hospital and Health Sciences System between September 2007 and April 2015. RESULTS: Fifteen patients (20.5%) presented with an anatomical variation of the RHA. Four patients had an accessory RHA and 11 had a totally replaced RHA. 50% of the cases were recognized by the radiologist preoperatively. There were no significant differences in the pre- and postoperative outcomes of the aberrant and normal RHA group. The mean number of harvested lymph nodes in the totally replaced RHA group was 22.8 ± 11.4. The rate of positive resection margins was 0% in the totally replaced RHA group and 9% in the normal RHA group. CONCLUSIONS: This study suggests that robotic PD has no negative impact on surgical and oncological outcomes in patients with a totally replaced RHA.

Heat conduction in live tissue during radiofrequency electrosurgery.

In this paper, we propose a method to model radiofrequency electrosurgery to capture the phenomena at higher temperatures and present the methods for parameter estimation. Experimental data taken from our surgical trials performed on in vivo porcine liver show that a non-Fourier Maxwell-Cattaneo-type model can be suitable for this application when used in combination with an Arrhenius-type model that approximates the energy dissipation in physical and chemical reactions. The resulting model structure has the advantage of higher accuracy than existing ones, while reducing the computation time required.

State of the art of robotic surgery in organ transplantation.

Within the last two decades the application of minimally invasive surgical technologies has shown significant benefits when it comes to complex surgical procedures. Lower rates of complications and higher patient satisfaction are commonly reported. Until recently these benefits were inaccessible for patients with solid organ transplantation, because conventional laparoscopy was seen as nonapplicable in such technically demanding procedures. The introduction of the da Vinci Robotic Surgical System, with its inherent advantages, has expanded the ability to complete solid organ transplantation in a minimally invasive fashion. Robotic applications in kidney, pancreas, and liver transplantation have been reported. The initial results showed the viability of this technique in the field. The most extensive experience has been described in kidney transplantation. Over 700 donor nephrectomies and more than 70 renal transplants have been performed successfully with the robotic system. The proven advantage of the robotic technique, especially in obese kidney recipients, is a significantly lower rate of surgical site infection, which in these highly immunosuppressed patients is reflected in superior outcomes. The first results in pancreas transplantation and living donor hepatectomy are very promising; however, larger series are needed in order to address the value of the robotic surgery in these areas of solid organ transplantation.

Minimally Invasive Live Tissue High-fidelity Thermophysical Modeling using Real-time Thermography.

We present a novel thermodynamic parameter estimation framework for energy-based surgery on live tissue, with direct applications to tissue characterization during electrosurgery. This framework addresses the problem of estimating tissue-specific thermodynamics in real-time, which would enable accurate prediction of thermal damage impact to the tissue and damage-conscious planning of electrosurgical procedures. Our approach provides basic thermodynamic information such as thermal diffusivity, and also allows for obtaining the thermal relaxation time and a model of the heat source, yielding in real-time a controlled hyperbolic thermodynamics model. The latter accounts for the finite thermal propagation time necessary for modeling of the electrosurgical action, in which the probe motion speed often surpasses the speed of thermal propagation in the tissue operated on. Our approach relies solely on thermographer feedback and a knowledge of the power level and position of the electrosurgical pencil, imposing only very minor adjustments to normal electrosurgery to obtain a high-fidelity model of the tissue-probe interaction. Our method is minimally invasive and can be performed in situ. We apply our method first to simulated data based on porcine muscle tissue to verify its accuracy and then to in vivo liver tissue, and compare the results with those from the literature. This comparison shows that parameterizing the Maxwell-Cattaneo model through the framework proposed yields a noticeably higher fidelity real-time adaptable representation of the thermodynamic tissue response to the electrosurgical impact than currently available. A discussion on the differences between the live and the dead tissue thermodynamics is also provided.

Minimally Invasive Live Tissue High-Fidelity Thermophysical Modeling Using Real-Time Thermography.

We present a novel thermodynamic parameter estimation framework for energy-based surgery on live tissue, with direct applications to tissue characterization during electrosurgery. This framework addresses the problem of estimating tissue-specific thermodynamics in real-time, which would enable accurate prediction of thermal damage impact to the tissue and damage-conscious planning of electrosurgical procedures. Our approach provides basic thermodynamic information such as thermal diffusivity, and also allows for obtaining the thermal relaxation time and a model of the heat source, yielding in real-time a controlled hyperbolic thermodynamics model. The latter accounts for the finite thermal propagation time necessary for modeling of the electrosurgical action, in which the probe motion speed often surpasses the speed of thermal propagation in the tissue operated on. Our approach relies solely on thermographer feedback and a knowledge of the power level and position of the electrosurgical pencil, imposing only very minor adjustments to normal electrosurgery to obtain a high-fidelity model of the tissue-probe interaction. Our method is minimally invasive and can be performed in situ. We apply our method first to simulated data based on porcine muscle tissue to verify its accuracy and then to in vivo liver tissue, and compare the results with those from the literature. This comparison shows that parameterizing the Maxwell-Cattaneo model through the framework proposed yields a noticeably higher fidelity real-time adaptable representation of the thermodynamic tissue response to the electrosurgical impact than currently available. A discussion on the differences between the live and the dead tissue thermodynamics is also provided.

Surgical opioid-avoidance protocol: a postoperative pharmacological multimodal analgesic intervention in diverse patient populations.

INTRODUCTION: This study evaluated the effect of a surgical opioid-avoidance protocol (SOAP) on postoperative pain scores. The primary goal was to demonstrate that the SOAP was as effective as the pre-existing non-SOAP (without opioid restriction) protocol by measuring postoperative pain in a diverse, opioid-naive patient population undergoing inpatient surgery across multiple surgical services. METHODS: This prospective cohort study was divided into SOAP and non-SOAP groups based on surgery date. The non-SOAP group had no opioid restrictions (n=382), while the SOAP group (n=449) used a rigorous, opioid-avoidance order set with patient and staff education regarding multimodal analgesia. A non-inferiority analysis assessed the SOAP impact on postoperative pain scores. RESULTS: Postoperative pain scores in the SOAP group compared with the non-SOAP group were non-inferior (95% CI: -0.58, 0.10; non-inferiority margin=-1). The SOAP group consumed fewer postoperative opioids (median=0.67 (IQR=15) vs 8.17 morphine milliequivalents (MMEs) (IQR=40.33); p<0.01) and had fewer discharge prescription opioids (median=0 (IQR=60) vs 86.4 MMEs (IQR=140.4); p<0.01). DISCUSSION: The SOAP was as effective as the non-SOAP group in postoperative pain scores across a diverse patient population and associated with lower postoperative opioid consumption and discharge prescription opioids.

Robotic versus laparoscopic distal pancreatectomy for pancreatic adenocarcinoma in obese patients.

BACKGROUND: Robotic distal pancreatectomy (RDP) is associated with a lower conversion rate and less blood loss than laparoscopic distal pancreatectomy (LDP). LDP has similar oncological outcomes as open surgery in PDAC. The aim of this study was to compare perioperative and oncological outcomes in obese patients with RDP versus LDP for PDAC. MATERIALS AND METHODS: Retrospectively, all obese patients who underwent RDP or LDP for PDAC between 2012 and 2022 at 12 international expert centres were included. RESULTS: out of 372, 81 patients were included. All baseline features were comparable between the two groups. RDP was associated with decreased blood loss (495mlLDP vs. 188mlRDP; p = 0.003), lower conversion rate (13.5%RDP vs. 36.4%LDP; p = 0.019) and lower rate of Clavien-Dindo ≥3 complications (13.5%RDP vs. 36.4%LDP; p = 0.019). Overall and disease-free survival were comparable. CONCLUSIONS: In obese patients with left-sided PDAC, the robotic approach was associated with improved intraoperative outcomes and fewer severe complications.

Robot-assisted subtotal pancreas-preserving duodenectomy.

BACKGROUND: Angiodysplasia of the duodenum is a rare disorder, often requiring surgical resection. Technical difficulties have made the use of the minimally invasive approach uncommon. Herein, we present a subtotal pancreas-preserving duodenectomy using robotic assistance. METHODS: The patient is a 60-y-old female with a long medical history including chronic gastrointestinal bleeding due to angiodysplasia with intermittent melena, and requiring multiples blood transfusions. A capsule endoscopy and double-balloon upper endoscopy showed angiectasis, which appeared to be limited to the third and fourth portion of the duodenum and the proximal loops of the jejunum. Despite multiple endoscopic cauterizations, the patient continued to require blood transfusion for several years. The patient underwent a robot-assisted subtotal pancreas-preserving duodenectomy. RESULTS: The operation lasted 420 min with minimal blood loss. The postoperative course was uneventful. The pathology report showed multiple small bowel mucosal and submucosal distorted and dilated vasculature, consistent with angiodysplasia. At 2-mo follow-up, the patient was totally asymptomatic. A barium swallow study showed contrast passed antegrade through the duodenojejunostomy with no evidence of obstruction, stricture, or leakage. CONCLUSION: The use of robotic assistance to perform a subtotal pancreas-preserving duodenectomy for the treatment of benign duodenal disease, such as angiodysplasia, is feasible and safe. The technical advantages include a high degree of freedom offered by the robotic instruments, as well as enhanced visualization, which allows for precise microdissection and microsuture, thereby preserving the benefits of minimally invasive surgery. The use of robotic technology allows for a wider range of indications for minimally invasive surgery.

Robotic-assisted central pancreatectomy: A minimally invasive approach for benign and low-grade lesions.

BACKGROUND: Centrally located pancreatic lesions are often treated with extended pancreaticoduodenectomy or distal pancreatectomy resulting in loss of healthy parenchyma and a high risk of diabetes and exocrine insufficiency. Robotic central pancreatectomy (RCP) is a parenchyma sparring alternative that has been shown safe and feasible [1,2]. METHODS: In this article, we describe our operative technique and the perioperative outcomes of a series of RCP for low-grade or benign pancreatic tumors. RESULTS: Six patients (5 female and 1 man) with a median age of 51.5 (44-68) years underwent a RCP for 2 serous cystadenomas, 2 mucinous cystic tumors, 1 neuroendocrine tumor, and 1 autoimmune pancreatitis. There were no conversions, intraoperative complications, or perioperative transfusions. Median operative time and was 240 (230-291) minutes and median blood loss was 100 (100-400) ml. The median hospital stay was 8 (5-27) days. There were no mortalities, reoperations, or readmissions. One patient developed a grade B pancreatic fistula which was successfully managed conservatively. All resections had free margins and the median tumor size was 2.5 (1.5-3.5) cm. After a mean follow-up of 46 months, no patients presented new-onset diabetes or exocrine insufficiency. CONCLUSIONS: RCP represents the least invasive option for both the patient and the pancreatic parenchyma. With a standardized technique, RCP results in low postoperative morbidity and excellent long-term pancreatic function. Although our results are excellent, POPF still represents the main complication of central pancreatectomy with an incidence ranging from 0 to 80% depending on multiple factors such as the surgeon, technique, and pancreatic texture.

Robotic single-port surgery: Preliminary experience in general surgery.

BACKGROUND: We aim to analyse the safety and feasibility of the DaVinci Single Port (SP) platform in general surgery. METHODS: A prospective series of robotic SP transabdominal pre-peritoneal inguinal hernia repairs (SP-TAPP) and cholecystectomies (SP-C) (off-label) were analysed. Primary endpoints were safety and feasibility defined by the need for conversion and incidence of perioperative complications. RESULTS: A total of 225 SP procedures were performed; 84 (37.3%) SP-TAPP (70 unilateral, 7 bilateral), and 141 (62.7%) SP-C. There were no conversions or additional ports placed. Mean console time was 17.6, 31.9, and 54 min for SP-C, unilateral, and bilateral SP-TAPP, respectively. There was no mortality, intraoperative or major postoperative complications. Mean LOS was 2.7 h for elective SP-TAPP and 2.3 h for SP-C. CONCLUSION: Robotic SP surgery is safe and feasible for two of the most performed general surgery operations. Further experience might allow expanding the applications of robotic single-incision surgery for other procedures.

Simultaneous Robotic-Assisted Bilateral Native Nephrectomy and Kidney Transplantation for Autosomal Dominant Polycystic Kidney Disease in Recipients With High Body Mass Index: Report of 2 Cases.

Robotic kidney transplantation is a safe, reproducible, and less morbid technique in high body mass index and end-stage renal disease. Polycystic kidney disease is a relative contraindication to robotic-assisted kidney transplantation because of the mass effect of the native kidneys on the patient's pelvis that prevents ideal exposure. We report the first 2 cases of robotic-assisted simultaneous bilateral nephrectomy and kidney transplantation for patients with obesity and adult polycystic kidney disease. The recipients were 2 males, 50 and 53 years old, with a body mass index of 35.1 41.6 kg/m2 and 41.6 kg/m2, respectively. Both recipients had suitable living donors. The average operating time was 395 minutes and the estimated blood loss was on average 250 mL. The postoperative course was uneventful and the patients were discharged home on days 4 and 5. Performing robotic nephrectomies simultaneously with kidney transplantation can be done safely, allowing patients with obesity and polycystic kidney disease needing bilateral nephrectomy, to take full advantage of minimally invasive kidney transplantation.

Robot-assisted treatment of splenic artery aneurysms.

BACKGROUND: Although splenic artery aneurysms (SAAs) are relatively uncommon, they are clinically relevant because of the risk of rupture. Optimal management is a matter of debate and involves the use of percutaneous endovascular stenting, which has limitations, versus the open surgical approach which can lead to significant morbidity. The present study reports the outcomes of robot-assisted surgery for SAA and its role in overcoming many of the limitations of laparoscopy. METHODS: A total of nine patients with incidentally detected SAAs underwent a surgery between September 2001 and November 2007. Six of these nine patients underwent a robot-assisted splenic aneurysm resection with vascular reconstruction. The remaining three cases included one robotic arterial ligation, one robotic partial splenectomy, and one laparoscopic splenectomy. RESULTS: The mean operating time was 212 ± 61 minutes (range: 90-300), mean intraoperative blood loss was 186.6 ± 202.4 mL (range: 0-500), and mean hospital stay was 7.1 ± 3.7 days (range: 3-14). The morbidity rate was 11.1% and no mortality was reported. Doppler-ultrasonography surveillance showed regular organ perfusion in all patients with vascular reconstruction. CONCLUSION: Robot-assisted surgery for SAA represents one of the most advanced developments among minimally invasive procedures and can become an important option for the treatment of this disease.

Robotic liver surgery: literature review and future perspectives.

INTRODUCTION: Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations. EVIDENCE ACQUISITION: A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR. EVIDENCE SYNTHESIS: The literature review results are presented and our additional remarks on the topic are discussed. CONCLUSIONS: Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Colonic leiomyoma mimicking a liver tumor: an unusual diagnosis after en-block robotic resection.

Colonic leiomyomas are rare. Their clinical presentation ranges from asymptomatic polyps detected on endoscopy to large symptomatic abdominopelvic masses. Imaging findings are usually non-specific, and percutaneous biopsy might help with differential diagnosis. However, radical surgery with negative margins is ultimately needed to rule out malignancy. We describe an uncommon presentation of a colonic leiomyoma mimicking a right hepatic lobe tumor on preoperative imaging. The robotic approach allowed a precise abdominal exploration with confirmation of colonic and hepatic infiltration and subsequent oncological en-block resection. Surgeons operating on hepatic tumors close to the right colic flexure should be aware of this diagnosis.